Auditor, Clinical Validation – Outpatient Specialty

Cotiviti

. Audit outpatient and specialty claims, including APC, PNPP, pharmacy, and/or inpatient DRG claims .

Posted 10/2/2026full-timeRemote • United StatesMid-LevelSenior💰 $46 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical medical record coding and auditing, with a strong focus on DRG, ICD-10, CPT, and HCPCS codes. Proficient in applying coding principles and guidelines while ensuring compliance with HIPAA and CMS regulations.

Highest-signal resume keywords

Active/Unrestricted Nursing LicenseCoding Certification (CPC, CIC, CCS, CCS-P, RHIA, RHIT)5-7 Years of Clinical Medical Record Coding ExperienceExpert Knowledge of DRG, ICD-10, CPT, and HCPCS CodesWorking Knowledge of HIPAA Privacy and Security Rules

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Chart ValidationMedical Record ReviewCoding Accuracy AssessmentClaims AuditingMedical Necessity EvaluationCoding TerminologyAudit Process ImprovementClaims EntryRegulatory Compliance AdherenceProductivity and Quality Standards

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationIndependent Work AbilityTeam Collaboration

Tools & Technologies

Cotiviti EncoderCotiviti SystemAudit Tools

Certifications & Qualifications

Active/Unrestricted Nursing LicenseCoding Certification (CPC, CIC, CCS, CCS-P, RHIA, RHIT)

Industry Keywords

Medical Claims BillingPayer Reimbursement PoliciesProvider Billing GuidelinesCMS Security RequirementsCoding GuidelinesCoding Clinic Determinations

About the role

Key responsibilities & impact

Audit outpatient and specialty claims, including APC, PNPP, pharmacy, and/or inpatient DRG claims
Perform coding and clinical chart validation for outpatient and specialty audits
Review and interpret medical records to identify billing and coding issues
Assess clinical review, coding accuracy, medical necessity, treatment setting, and services delivered
Apply medical chart coding principles and client-specific guidelines
Use Cotiviti Encoder and audit tools
Enter claims accurately into the Cotiviti system
Meet productivity, accuracy, quality, and valid claim identification/documentation standards
Identify potential claims outside the assigned audit concept where additional recoveries may be available
Suggest and develop audit concepts, process improvements, tools, and technological improvements
Implement ideas and approaches supporting audit production, communication, and client satisfaction
Evaluate information and draw logical conclusions
Complete responsibilities in the annual Performance Plan and special projects or other assigned duties

Requirements

What you’ll need

Associate or bachelor’s degree in nursing
Active/unrestricted nursing license
Coding certification required and maintained, such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT
5 to 7 years of experience with clinical medical record coding or auditing
Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements
Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology
Ability to learn and become proficient in outpatient and specialty review types
Adherence to official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates
Expert knowledge of DRG, ICD-10, CPT, and HCPCS codes
Excellent verbal and written communication skills
Ability to work independently and in a team environment
Ability to provide a dedicated, secure work area
Ability to provide high-speed internet access/connectivity and office setup and maintenance
Must be able to perform duties with or without reasonable accommodation

Benefits

Comp & perks

Discretionary bonus consideration
Medical insurance
Dental insurance
Vision insurance
Disability insurance
Life insurance
401(k) savings plan
Paid family leave
9 paid holidays per year
17–27 days of Paid Time Off (PTO) per year, depending on level and length of service
Overtime pay for nonexempt employees for hours worked over 40 per week or as required by state law
Remote work arrangement
Dedicated, secure work area and high-speed internet/office setup provided by the team member